Summary Key Points
Definition and Classification
BACTERIAL
Medical Emergency
Immediate recognition and treatment required
VIRAL
Self-limiting
Supportive management generally sufficient
OTHER
Fungal, Parasitic, Non-infectious
Varies by causative agent
Critical Recognition and Timing
Time-critical condition: Antibiotics should be administered within 60 minutes of recognition
- Classical triad (fever, neck stiffness, altered mental state) present in <50% of cases
- High index of suspicion required, particularly in high-risk groups
- Petechial/purpuric rash suggests meningococcal disease
- Lumbar puncture should not delay antibiotic therapy if bacterial meningitis suspected
High-Risk Populations
Paediatric
Infants and children under 5 years
Elderly
Adults over 60 years
Immunocompromised
HIV, malignancy, immunosuppressive therapy
Functional or anatomical asplenia
Complement deficiencies
Aboriginal and Torres Strait Islander
Higher rates of invasive pneumococcal and meningococcal disease
Additional high-risk groups: Close contacts of confirmed cases
Immediate Management Priorities
1
ABC Assessment
Airway, breathing, circulation assessment
2
Rapid Antibiotics
For suspected bacterial meningitis
3
Dexamethasone
Administration per specific indications
4
ICP Management
Management of raised intracranial pressure
5
Isolation
Precautions until bacterial meningitis excluded
6
Contact Management
Contact tracing and chemoprophylaxis for meningococcal disease
Key Investigations
Essential
Blood cultures
Before antibiotics (if no delay to treatment)
Essential
Lumbar puncture with CSF analysis
Cell count, protein, glucose, microscopy, culture, PCR
Essential
Serum glucose
Concurrent with CSF glucose
Available
Blood PCR
For common bacterial pathogens
Specialist
Imaging (CT/MRI)
If contraindications to lumbar puncture
Notification Requirements
- All cases of meningococcal disease are notifiable under National Notifiable Diseases Surveillance System (NNDSS)
- Pneumococcal disease (invasive) notifiable in some jurisdictions
- Contact local public health unit immediately for meningococcal disease
Prevention Strategies
Vaccination Programs
- Meningococcal ACWY and B vaccines
- Pneumococcal vaccines
- Hib vaccine
- Enhanced vaccination schedules for Aboriginal and Torres Strait Islander children
Other Prevention
- Chemoprophylaxis for close contacts of meningococcal cases
- Standard and droplet precautions in healthcare settings
Introduction
Meningitis is a medical emergency characterised by inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. In Australia, meningitis represents a significant public health concern with high morbidity and mortality rates if not promptly recognised and treated.
The condition can be caused by bacterial, viral, fungal, or parasitic pathogens, with bacterial meningitis being the most severe and requiring immediate intervention.
Epidemiology
The epidemiology of meningitis in Australia has evolved significantly following the introduction of comprehensive vaccination programs. Haemophilus influenzae type b (Hib) meningitis has virtually disappeared since routine childhood vaccination began in 1993. Similarly, pneumococcal conjugate vaccines (PCV7, PCV13) and meningococcal vaccines (MenC, ACWY, MenB) have dramatically reduced disease incidence for their respective serotypes.
Current Surveillance Data (NNDSS)
- Invasive meningococcal disease: approximately 1.5-2 cases per 100,000 population annually
- Invasive pneumococcal disease: 8-12 cases per 100,000 population annually
- Group B Streptococcus: predominantly affects neonates and elderly populations
Pathogen Distribution by Age Groups
Neonates (0-28 days)
Group B Streptococcus (GBS): 40-50% of cases
Escherichia coli and other Gram-negative bacilli: 30-35%
Listeria monocytogenes: 5-10%
Infants and children (1 month - 18 years)
Neisseria meningitidis: 50-60% of bacterial cases
Streptococcus pneumoniae: 20-30%
Haemophilus influenzae (non-type b strains): <5%
Adults (18-50 years)
Neisseria meningitidis: 40-50%
Streptococcus pneumoniae: 30-40%
Older adults (>50 years)
Streptococcus pneumoniae: 50-60%
Neisseria meningitidis: 20-30%
Listeria monocytogenes: 10-15%
High-Risk Populations
Certain populations face increased risk of meningitis due to immunocompromise, anatomical factors, or social determinants:
Immunocompromised patients
Malignancy, particularly haematological
Solid organ or bone marrow transplant recipients
Primary immunodeficiencies (complement deficiencies, asplenia)
HIV infection with CD4+ count <200 cells/ฮผL
Chronic corticosteroid use or other immunosuppressive therapy
Aboriginal and Torres Strait Islander peoples
Experience higher rates of invasive bacterial infections
Often present with more severe disease
May have delayed access to healthcare in remote communities
Higher prevalence of risk factors including overcrowding, chronic diseases
Anatomical or device-related risks
CSF leaks (traumatic, surgical, congenital)
Cochlear implants
Ventriculoperitoneal shunts
Recent neurosurgery or head trauma
Clinical Significance
Bacterial meningitis remains a neurological emergency with case fatality rates of 10-20% despite appropriate antibiotic therapy.
Survivors frequently experience significant long-term sequelae including:
- Sensorineural hearing loss (10-30% of cases)
- Cognitive impairment and learning difficulties
- Seizure disorders
- Motor deficits and cerebral palsy
- Hydrocephalus
Early recognition and treatment within the first hour of presentation significantly improves outcomes and reduces the risk of permanent neurological damage. The "time is brain" principle applies critically in bacterial meningitis management.
Healthcare System Impact
Meningitis places considerable burden on the Australian healthcare system through:
- Emergency department presentations requiring urgent evaluation
- Intensive care unit admissions for severe cases
- Extended hospital stays for treatment and monitoring
- Long-term rehabilitation and support services
- Contact tracing and chemoprophylaxis programs
- Public health investigation and response activities
The condition also generates significant anxiety within communities, particularly when cases occur in schools, universities, or other institutional settings, requiring coordinated public health communication and management strategies.
Microbiology
Bacterial Pathogens
Streptococcus pneumoniae
Characteristics
Gram-positive diplococci, alpha-haemolytic, encapsulated with >90 serotypes
Prevalence
Most common cause in adults and children >2 years in Australia
Resistance
Penicillin: ~15% intermediate, ~5% high-level resistance
Risk Factors
Immunocompromise, CSF leak, cochlear implant, splenectomy
Mortality
15-30% despite appropriate treatment
Neisseria meningitidis
Characteristics
Gram-negative diplococcus, highly transmissible via respiratory droplets
Prevalence
Leading cause in children and young adults
Serogroups
B (60% in Australia), C (20%), Y, W135, A
Progression
Rapid progression from colonisation to invasive disease
Case Fatality
5-10% with treatment, >50% without treatment
Haemophilus influenzae
Characteristics
Gram-negative coccobacillus, predominantly type b (Hib)
Impact
Dramatic reduction since Hib vaccination (1992)
Current Pattern
Non-typeable strains increasingly recognised in adults
Risk Factors
Immunodeficiency, CSF leak, head trauma
Listeria monocytogenes
Characteristics
Gram-positive rod, beta-haemolytic
Risk Groups
Neonates, elderly (>60 years), immunocompromised
Transmission
Foodborne (soft cheeses, deli meats, unpasteurised dairy)
Resistance
Ampicillin-sensitive, intrinsically resistant to cephalosporins
Mortality
20-30%
Group B Streptococcus
Characteristics
Gram-positive chain-forming cocci, beta-haemolytic
Prevalence
Leading cause of neonatal bacterial meningitis in Australia
Patterns
Early-onset (<7 days) vs late-onset (7 days-3 months)
Maternal Colonisation
15-30% of pregnant women
Treatment
Penicillin remains first-line therapy
Enterobacteriaceae
Importance
Increasing in healthcare-associated meningitis
E. coli
Leading cause of neonatal meningitis
K. pneumoniae
Associated with neurosurgical procedures
ESBL Rates
15-25% in Australia
Resistance Concern
Carbapenem resistance emerging
N. meningitidis is a notifiable disease requiring immediate notification due to its rapid progression and high transmission risk.
Viral Pathogens
Enteroviruses
Prevalence
Most common cause of viral meningitis (>85% cases)
Seasonality
Summer-autumn predominance
Serotypes
Coxsackievirus A and B, Echovirus, Enterovirus 71
Course
Self-limiting in immunocompetent hosts
Diagnosis
PCR on CSF
Herpes Simplex Virus
HSV-2
Recurrent viral meningitis (Mollaret's meningitis)
HSV-1
Typically encephalitis rather than isolated meningitis
Diagnosis
PCR sensitivity >95% for CSF diagnosis
Treatment
Aciclovir effective for HSV-2 meningitis
Other Viral Pathogens
VZV
Reactivation in immunocompromised/elderly, associated with zoster rash
EBV
Rare cause, associated with infectious mononucleosis syndrome
Parechovirus
Emerging cause of neonatal meningitis, requires specific PCR
Fungal and Other Pathogens
Cryptococcus species
Prevalence
Leading cause of fungal meningitis in Australia
C. neoformans
HIV-associated disease
C. gattii
Immunocompetent hosts, endemic in northern Australia
Diagnosis
CSF India ink, antigen detection, culture
Mycobacterium tuberculosis
Prevalence
Accounts for 1-5% of all TB cases
Presentation
Subacute presentation over weeks
CSF Pattern
Lymphocytic pleocytosis, low glucose, high protein
Diagnosis
Acid-fast bacilli, PCR, culture (slow-growing)
Cryptococcus and tuberculous meningitis have high mortality without treatment and require prolonged therapy.
Age-Specific Pathogen Distribution
Neonates (0-28 days)
Group B Streptococcus (40-50%)
E. coli and other Gram-negative bacilli (20-30%)
L. monocytogenes (5-10%)
HSV-2 (5%)
Infants and Children (1 month-16 years)
S. pneumoniae (40-50%)
N. meningitidis (25-35%)
H. influenzae type b (<5% post-vaccination)
Adults (17-64 years)
S. pneumoniae (50-60%)
N. meningitidis (15-25%)
L. monocytogenes (5-10%)
Elderly (>65 years)
S. pneumoniae (50-60%)
L. monocytogenes (15-20%)
Gram-negative bacilli (10-15%)
Australian Antimicrobial Resistance Patterns
| Pathogen | Antibiotic | Resistance Rate | Notes |
|---|---|---|---|
| S. pneumoniae | Penicillin | ~20% non-susceptible | Intermediate + high-level |
| S. pneumoniae | Ceftriaxone | <5% | Resistance rare |
| N. meningitidis | Penicillin | <5% | Reduced susceptibility |
| H. influenzae | Ampicillin | 15-20% | Beta-lactamase production |
Diagnostic Considerations
CSF Analysis Patterns
- Bacterial: neutrophilic pleocytosis, low glucose, high protein
- Viral: lymphocytic pleocytosis, normal/mildly low glucose, mildly elevated protein
- Fungal: lymphocytic pleocytosis, low glucose, very high protein
- Tuberculous: lymphocytic pleocytosis, very low glucose, very high protein
Molecular Diagnostics
- CSF PCR: high sensitivity for viral pathogens
- Bacterial PCR: useful post-antibiotic treatment
- 16S rRNA PCR: culture-negative bacterial meningitis
- Multiplex PCR: panels available for common pathogens
PCR testing significantly improves diagnostic yield, especially for viral pathogens and in cases where antibiotics have been administered prior to lumbar puncture.
Clinical Presentation
Classic Meningeal Syndrome
The classic triad of fever, neck stiffness, and altered mental state occurs in only 44-46% of patients with bacterial meningitis.
Individual components are present in:
- Fever: 95% of cases
- Neck stiffness: 88% of cases
- Altered mental state: 78% of cases
- Headache: 87% of cases
Early Clinical Features
Nonspecific prodromal symptoms (6-24 hours)
- Malaise and fatigue
- Upper respiratory tract symptoms
- Myalgia and arthralgia
- Nausea and vomiting
- Photophobia and phonophobia
- Irritability (particularly in children)
Progressive neurological symptoms
- Severe headache (typically generalised, constant, and worsening)
- Neck stiffness and pain
- Altered consciousness (confusion, lethargy, stupor)
- Seizures (occur in 20-30% of cases)
- Focal neurological deficits
Physical Examination Findings
Meningeal Signs
Essential
Neck stiffness (nuchal rigidity)
Resistance to passive neck flexion. May be absent in elderly, immunocompromised, or very young patients. Can be masked by altered consciousness
Available
Kernig's sign
With hip flexed at 90ยฐ, pain and resistance when extending knee. Sensitivity 5-37%, specificity 95-100%
Available
Brudzinski's sign
Spontaneous hip and knee flexion when neck is passively flexed. Sensitivity 5-30%, specificity 95-100%
Neurological Assessment
- Glasgow Coma Scale assessment
- Cranial nerve examination (particularly II, III, VI, VII, VIII)
- Motor and sensory examination
- Deep tendon reflexes
- Plantar responses
- Assessment for papilloedema
Systemic Examination
Cardiovascular
- Tachycardia
- Hypotension (may indicate septic shock)
- Signs of endocarditis
Dermatological
- Petechial or purpuric rash (particularly with meningococcal disease)
- Other rashes suggesting specific pathogens
Age-Specific Presentations
Neonates and Infants (<3 months)
Classic signs often absent
Non-specific symptoms predominate:
- Fever or hypothermia
- Poor feeding and irritability
- Lethargy or excessive sleepiness
- High-pitched cry
- Bulging fontanelle (late sign)
- Seizures
- Apnoea or respiratory distress
- Jaundice
- Vomiting or diarrhoea
Children (3 months - 5 years)
- Fever and irritability most common
- Neck stiffness may be subtle or absent
- Behavioural changes
- Refusal to walk or bear weight
- Photophobia
- Seizures more common than in adults
- Rapid deterioration possible
Elderly Patients (>65 years)
Often atypical presentation - classic triad present in <25%
May present with:
- Confusion or delirium
- Falls
- Focal neurological deficits
- Absence of fever (up to 35%)
- Minimal neck stiffness
Immunocompromised Patients
- Blunted inflammatory response
- May lack fever or meningeal signs
- Subtle neurological changes
- Rapid progression common
- Higher risk of opportunistic pathogens
Pathogen-Specific Clinical Features
Rapid Onset
Meningococcal Meningitis
Neisseria meningitidis
- Rapid onset and progression (hours)
- Petechial or purpuric rash in 50-80%
- Rash may be initially blanching
- High risk of septic shock
- Adrenal haemorrhage (Waterhouse-Friderichsen syndrome)
Gradual Onset
Pneumococcal Meningitis
Streptococcus pneumoniae
- More gradual onset
- Higher rates of focal neurological deficits
- Associated pneumonia in 50%
- Hearing loss more common
- Higher mortality and morbidity
Rare
Haemophilus influenzae Type b
Now rare due to vaccination
- Gradual onset over days
- Associated upper respiratory infection
- Subdural effusions more common in children
High Risk Groups
Listeria monocytogenes
Elderly, immunocompromised, pregnant
- Gradual onset
- Brainstem involvement with cranial nerve palsies
- Movement disorders
- Seizures less common
Neonatal
Group B Streptococcus
Primarily affects neonates
- Early-onset: respiratory distress, apnoea
- Late-onset: fever, poor feeding, irritability
Generally Milder
Viral Meningitis
Various viral pathogens
- Gradual onset over days
- Fever typically lower grade
- Less severe headache and neck stiffness
- Preserved consciousness more common
- Photophobia prominent
- Associated viral syndrome symptoms
- Seasonal patterns (enteroviruses in summer/autumn)
Complications and Warning Signs
Immediate Life-Threatening Features
- Altered consciousness (GCS <13)
- Signs of raised intracranial pressure: papilloedema, Cushing's triad, focal neurological signs
- Seizures (focal or generalised)
- Signs of septic shock
- Respiratory compromise
Early Complications
- Cerebral oedema
- Hydrocephalus
- Subdural effusions or empyema
- Cerebral infarction
- Venous sinus thrombosis
- Cranial nerve palsies
- Hearing loss
Red Flag Features Requiring Immediate Assessment
- Non-blanching rash with fever
- Altered consciousness or confusion
- Seizures
- Focal neurological deficits
- Signs of raised intracranial pressure
- Hypotension or shock
- Rapid clinical deterioration
- Immunocompromised state with neurological symptoms
ATSI Health Considerations
Aboriginal and Torres Strait Islander patients may present with:
- Higher rates of pneumococcal meningitis
- Co-existing chronic conditions affecting presentation
- Potential for delayed presentation due to access issues
- Cultural considerations in symptom reporting
- Higher rates of complications including hearing loss
- Consider rheumatic heart disease as predisposing factor
Investigations
Immediate Investigations
Lumbar Puncture and CSF Analysis
Mandatory unless contraindicated - perform immediately after blood cultures if no contraindications
Contraindications:
- Signs of raised ICP (papilloedema, focal neurological signs, altered consciousness with bradycardia and hypertension)
- Coagulopathy (INR >1.4, platelets <50 x 10โน/L)
- Infection at puncture site
- Cardiorespiratory compromise
Essential
Cell count and differential
Urgent processing required
Essential
Protein and glucose levels
Essential
Gram stain and microscopy
Urgent processing required
Essential
Bacterial culture and sensitivities
Available
Pneumococcal and meningococcal antigen tests
Specialist
PCR Panel
Meningococcus, Pneumococcus, H. influenzae, Listeria, HSV-1/2, VZV, Enterovirus
Additional CSF Tests (if clinically indicated):
Specialist
Cryptococcal antigen and India ink stain
Specialist
Mycobacterial culture and PCR
Specialist
Cytology for malignant cells
Specialist
Oligoclonal bands and IgG index
If demyelinating disease suspected
Blood Investigations
Within 30 minutes
Essential
Blood cultures x2 sets
Before antibiotics if possible
Essential
FBC with differential
Essential
UEC including creatinine
Essential
LFTs
Essential
Coagulation studies (PT/INR, APTT)
Essential
Glucose
For CSF:serum glucose ratio
Available
CRP and procalcitonin
Essential
Blood gas analysis
Additional Blood Tests:
Specialist
Meningococcal and pneumococcal PCR
Available
Serology for atypical organisms
If subacute presentation
Available
HIV serology
If risk factors present
Specialist
Complement levels (C3, C4, CH50)
If recurrent disease
Imaging Studies
CT Brain
Indications for CT before LP:
- New focal neurological deficit
- Papilloedema
- Abnormal level of consciousness (GCS <12)
- Immunocompromised state
- History of CNS mass lesion
- New onset seizure
- Age >60 years with altered mental status
CT with contrast indicated for: Suspected brain abscess, subdural empyema, cerebral venous thrombosis
MRI Brain
Consider if:
- Recurrent meningitis
- Unusual presentation
- Complications suspected (venous thrombosis, abscess)
- HSV encephalitis suspected
- Normal CT but ongoing concern for complications
Microbiological Investigations
Culture and Sensitivity Testing
- CSF bacterial culture (minimum 48-72 hours incubation)
- Blood cultures (48-72 hours with extended incubation for fastidious organisms)
- Throat swab for meningococcus (close contacts)
- Sputum culture if pneumonia suspected
Rapid Diagnostic Tests
- CSF antigen detection for S. pneumoniae, N. meningitidis, H. influenzae type b
- Lateral flow immunoassays (where available)
Molecular Diagnostics: Real-time PCR panels, multiplex PCR for viral causes, 16S rRNA sequencing for culture-negative cases, whole genome sequencing for outbreak investigation
Specialised Investigations
For Specific Populations
Neonates and Infants (<3 months)
Urine culture and microscopy
Chest X-ray
Consider HSV PCR even without skin lesions
Group B Streptococcus antigen
Immunocompromised Patients
Extended viral PCR panel including CMV, EBV, HHV-6
Fungal culture and antigen tests
Mycobacterial studies
Toxoplasma serology and PCR
JC virus PCR if progressive multifocal leukoencephalopathy suspected
ATSI Patients
Enhanced surveillance for pneumococcal serotypes
Consider extended incubation for fastidious organisms
Rheumatic heart disease screening if indicated
Complications Assessment
If complications suspected:
Available
Repeat CT/MRI at 24-48 hours
Specialist
Transcranial Doppler ultrasound
For vasospasm
Referral
Audiometry
Baseline and follow-up
Referral
Ophthalmological examination
Available
Echocardiogram
If endocarditis suspected
Laboratory Reference Values
Normal CSF Parameters (Adults)
| Parameter | Normal Range |
|---|---|
| Opening pressure | 6-25 cmHโO |
| White cells | <5 x 10โถ/L |
| Protein | 0.15-0.45 g/L |
| Glucose | >60% of serum glucose |
| Lactate | <2.2 mmol/L |
CSF Patterns by Aetiology
| Aetiology | Cells/ฮผL | Predominant Cell | Protein g/L | Glucose |
|---|---|---|---|---|
| Bacterial | 1000-5000+ | Neutrophils | 1.0-5.0+ | Low (<2.2 mmol/L) |
| Viral | 10-1000 | Lymphocytes | 0.5-1.0 | Normal |
| Tuberculous | 50-500 | Lymphocytes | 1.0-3.0 | Very low |
| Fungal | 20-500 | Lymphocytes | 0.5-3.0 | Low |
Quality Assurance
Specimen Handling
- CSF analysis within 30 minutes of collection
- Keep specimens at room temperature for bacterial culture
- Refrigerate viral specimens if delay >2 hours
- Dedicated pneumatic tube system for urgent specimens
Antimicrobial Stewardship
- Document pre-antibiotic specimens obtained
- Communicate results immediately to treating team
- De-escalate therapy based on culture results
- Monitor antimicrobial resistance patterns locally
Antimicrobial Stewardship
Principles of Antimicrobial Stewardship in Meningitis
Antimicrobial stewardship is critical in meningitis management to optimise patient outcomes while minimising antimicrobial resistance development. The urgent nature of suspected meningitis requires immediate empirical therapy initiation, followed by targeted therapy based on microbiological results.
Pre-treatment Considerations
Microbiological Sampling Strategy
- Obtain blood cultures before antimicrobial administration whenever possible
- CSF collection should not delay empirical therapy in critically unwell patients
- Consider rapid diagnostic tests (PCR, antigen detection) to guide early therapy
- Document sampling timing relative to antimicrobial administration
Risk Stratification for Empirical Therapy Selection
- Patient age and immune status
- Local epidemiological patterns and resistance data
- Recent antimicrobial exposure history
- Healthcare-associated risk factors
- Travel history and endemic pathogen exposure
Empirical Therapy Duration and Review Points
0-48 hours
Initial Empirical Phase
- Start empirical therapy immediately in suspected meningitis
- Document clear indication and expected pathogen coverage
- Schedule mandatory clinical and microbiological review at 24-48 hours
- Ensure appropriate dose optimisation for CNS penetration
48-72 hours
Early Directed Phase
- Review all available microbiological results
- Switch to pathogen-directed therapy when organism identified
- Rationalise antimicrobial spectrum to narrowest effective agent
- Consider discontinuation if alternative diagnosis confirmed
Pathogen-Specific Antimicrobial Optimisation
Streptococcus pneumoniae
Pathogen-Specific Management
Penicillin-susceptible
Switch to benzylpenicillin
Reduced penicillin susceptibility
Continue ceftriaxone or cefotaxime
Monitoring
Monitor for vancomycin-resistant strains
Special consideration
Consider corticosteroid interaction with antimicrobial efficacy
Neisseria meningitidis
Pathogen-Specific Management
Penicillin-susceptible
Switch to benzylpenicillin
Penicillin-resistant
Maintain ceftriaxone
Contact management
Assess prophylaxis indication for close contacts
Notification
Notify public health authorities immediately
Haemophilus influenzae
Pathogen-Specific Management
ฮฒ-lactamase negative
Switch to ampicillin
ฮฒ-lactamase positive
Continue cephalosporin therapy
ฮฒ-lactam allergy
Consider chloramphenicol
Assessment
Check vaccination status and close contact prophylaxis needs
Listeria monocytogenes
Pathogen-Specific Management
First-line
Ampicillin remains first-line therapy
Severe cases
Add gentamicin for synergistic effect
Avoid
Cephalosporins (intrinsically resistant)
Duration
Extended duration therapy often required
Duration of Therapy Optimisation
Evidence-Based Duration Guidelines
Streptococcus pneumoniae
10-14 days
Neisseria meningitidis
5-7 days
Haemophilus influenzae
7-10 days
Listeria monocytogenes
14-21 days
Group B Streptococcus
14-21 days
Factors Influencing Duration Extension
- Immunocompromised state
- Delayed clinical response
- Complicated course (abscess, ventriculitis)
- Resistant organism identification
- CSF sterilisation delay
Monitoring and Adjustment Strategies
Clinical Response Assessment
- Daily neurological assessment and Glasgow Coma Scale
- Temperature trend monitoring
- Inflammatory marker trajectory (CRP, procalcitonin)
- CSF improvement parameters when repeat lumbar puncture indicated
Antimicrobial Level Monitoring
- Vancomycin trough levels when used
- Consider CSF penetration adequacy for critical cases
- Adjust dosing for renal function changes
- Monitor for drug-related toxicity
Special Populations Stewardship
Paediatric Considerations
Age-appropriate dosing calculations
Developmental pharmacokinetic considerations
Avoid antimicrobials with age-specific contraindications
Family education regarding compliance and completion
Immunocompromised Patients
Broader empirical coverage requirements
Extended therapy duration often necessary
Enhanced monitoring for treatment failure
Multidisciplinary team involvement
Pregnancy and Breastfeeding
Pregnancy-safe antimicrobial selection
Avoid teratogenic agents (chloramphenicol, fluoroquinolones)
Consider maternal-fetal drug transfer
Lactation safety assessment
Antimicrobial Resistance Considerations
Local Resistance Pattern Integration
- Regular review of institutional antibiograms
- Monitor emerging resistance trends
- Adjust empirical protocols based on local data
- Coordinate with microbiology laboratory
Carbapenem Stewardship
1
Reserve for documented multidrug-resistant organisms
2
Avoid empirical carbapenem use unless high resistance risk
3
Switch to narrower agents when susceptibilities available
4
Monitor for carbapenem-resistant Enterobacteriaceae emergence
Quality Improvement and Audit
Stewardship Metrics
- Time to appropriate therapy initiation
- Empirical to directed therapy conversion rate
- Average length of therapy by pathogen
- Clinical outcome correlation with stewardship interventions
Regular Review Processes
- Monthly antimicrobial usage data analysis
- Quarterly resistance trend review
- Annual empirical guideline review and update
- Multidisciplinary stewardship team meetings
De-escalation Strategies
Systematic Approach to Narrowing Therapy
1
Daily review of culture results and sensitivities
2
Switch from combination to monotherapy when appropriate
3
Reduce spectrum while maintaining efficacy
4
Document rationale for continued broad-spectrum therapy
Culture-Negative Meningitis Management
- Consider alternative diagnoses
- Assess response to empirical therapy
- Limit therapy duration based on clinical improvement
- Avoid prolonged broad-spectrum coverage without clear indication
Prophylaxis Stewardship
Close Contact Prophylaxis
- Risk assessment for transmission likelihood
- Appropriate agent selection and duration
- Public health coordination
- Documentation of prophylaxis recipients
Secondary Prevention
- Vaccination recommendations post-recovery
- Immunodeficiency investigation when appropriate
- Long-term antimicrobial prophylaxis in selected cases
- Regular review of prophylaxis necessity
Special Populations
Neonates (0-28 days)
Blood-brain barrier immaturity increases susceptibility. Non-specific presentations: poor feeding, lethargy, temperature instability, apnoea. Lower threshold for lumbar puncture in febrile neonates.
High-risk pathogens: Group B Streptococcus, E. coli, Listeria monocytogenes
Empirical Therapy
Benzylpenicillin
(Crystapen)
Neonatal Dose
60 mg/kg IV every 12 hours (0-7 days), every 8 hours (8-28 days)
PBS Status
โ PBS General Benefit
Cefotaxime
(Claforan)
Neonatal Dose
50 mg/kg IV every 12 hours (0-7 days), every 8 hours (8-28 days)
Duration
Minimum 14 days for GBS, 21 days for gram-negative
Renal Adjustment
Reduce frequency if creatinine elevated
PBS Status
โ PBS General Benefit
Dexamethasone contraindicated in neonates. Consider IVIG in severe cases or immunocompromised neonates.
Infants and Children (1 month - 16 years)
Age-specific pathogens:
- 1-3 months: Group B Streptococcus, E. coli, Listeria, S. pneumoniae
- 3 months-5 years: S. pneumoniae, N. meningitidis, H. influenzae type b
- >5 years: S. pneumoniae, N. meningitidis
Empirical Therapy
1-3 months
Benzylpenicillin
Dose
60 mg/kg IV every 6 hours
PBS Status
โ PBS General Benefit
Cefotaxime
Dose
50 mg/kg IV every 6 hours
PBS Status
โ PBS General Benefit
>3 months
Ceftriaxone
(Rocephin)
Dose
100 mg/kg/day IV in 1-2 divided doses (max 4g/day)
PBS Status
โ PBS General Benefit
Vancomycin
(Vancocin)
Dose
15 mg/kg IV every 6 hours
Renal Adjustment
Monitor levels, adjust based on creatinine clearance
PBS Status
โ PBS General Benefit
Dexamethasone: Indicated for suspected pneumococcal meningitis in children >6 weeks. Give 0.15 mg/kg IV every 6 hours for 2-4 days before or with first antibiotic dose.
Pregnancy
Increased susceptibility due to altered cell-mediated immunity. Higher risk of Listeria monocytogenes. Fetal complications: preterm labour, stillbirth, neonatal infection.
Safe Antibiotics in Pregnancy
Benzylpenicillin
Safety
Safe in all trimesters
PBS Status
โ PBS General Benefit
Ampicillin
(Austrapen)
Dose
2g IV every 4 hours
Duration
Minimum 21 days for Listeria coverage
PBS Status
โ PBS General Benefit
Ceftriaxone
Safety
Safe, preferred third-generation cephalosporin
PBS Status
โ PBS General Benefit
Avoid: Chloramphenicol, trimethoprim-sulfamethoxazole. Always include ampicillin for Listeria coverage.
Immunocompromised Patients
High-risk groups:
- Haematological malignancy, solid organ transplant recipients
- HIV/AIDS (CD4 <200 cells/ฮผL)
- Chronic corticosteroid use (>20mg prednisolone daily >1 month)
- Complement deficiency, asplenia
- Diabetes mellitus, chronic kidney disease
Additional organisms to consider: Cryptococcus neoformans, Mycobacterium tuberculosis, Nocardia species, Toxoplasma gondii, Varicella-zoster virus
Empirical Therapy
Ampicillin
Dose
2g IV every 4 hours for Listeria
PBS Status
โ PBS General Benefit
Aciclovir
(Zovirax)
Dose
10 mg/kg IV every 8 hours
Indication
Consider for viral encephalitis
Renal Adjustment
Reduce dose if eGFR <50 mL/min/1.73mยฒ
PBS Status
โ PBS Authority Required
Dexamethasone: Use with extreme caution. Consider omitting if absolute neutrophil count <1000 cells/ฮผL.
Elderly Patients (โฅ65 years)
Often subtle presentations: altered mental status, falls, functional decline. Higher mortality and morbidity rates.
Common pathogens: S. pneumoniae (most common), N. meningitidis, Listeria monocytogenes (>60 years), Group B Streptococcus
Empirical Therapy
Ceftriaxone
Dose
2g IV every 12 hours
Renal Adjustment
Monitor if eGFR <30 mL/min/1.73mยฒ
PBS Status
โ PBS General Benefit
Ampicillin
Dose
2g IV every 4 hours (Listeria coverage)
PBS Status
โ PBS General Benefit
Vancomycin
Dose
25-30 mg/kg IV loading dose, then 15-20 mg/kg every 8-12 hours
Indication
If high pneumococcal resistance risk
Renal Adjustment
Essential monitoring, dose based on levels and creatinine clearance
PBS Status
โ PBS General Benefit
Dexamethasone benefits may be reduced in elderly. Use standard dosing: 0.15 mg/kg IV every 6 hours for 2-4 days. Monitor for hyperglycaemia, gastrointestinal bleeding.
Aboriginal and Torres Strait Islander Peoples
Higher incidence of invasive bacterial diseases. Earlier age of pneumococcal disease onset. Potential delays in healthcare access.
Renal Impairment
Dosing Adjustments - Severe Renal Impairment (eGFR <30 mL/min/1.73mยฒ)
Benzylpenicillin
Reduce to every 8-12 hours
Ceftriaxone
No adjustment usually required, but monitor
Vancomycin
Essential TDM, significant dose reduction needed
Aciclovir
Reduce 50% if eGFR 25-50, 75% if eGFR <25
Monitoring Requirements: Daily creatinine and electrolytes. Vancomycin levels (target trough 15-20 mg/L for CNS infections). Consider nephrology consultation for complex cases.
Hepatic Impairment
Most antibiotics require minimal dose adjustment. Avoid hepatotoxic agents where possible. Monitor liver function tests closely.
Ceftriaxone
Reduce dose if severe hepatic impairment (Child-Pugh C)
Chloramphenicol
Contraindicated in severe hepatic impairment
Rifampin
Monitor closely for hepatotoxicity
Follow-Up & Prevention
Immediate Follow-Up Requirements
Post-Discharge Monitoring
24-48 hours
Neurological assessment post-discharge
2-4 weeks
Audiometry for all patients (mandatory for pneumococcal and Hib meningitis)
As required
- Ophthalmological examination if visual symptoms reported
- Cognitive assessment for school-aged children and adults with prolonged illness
- Assessment of activities of daily living in elderly patients
Specific Organism Follow-Up
Pneumococcal
Audiometry at discharge, 6 weeks, 3 months, and 6 months
Meningococcal
Neurological review at 4-6 weeks; audiometry at 6 weeks
Hib
Comprehensive developmental assessment for children
Group B Strep
Enhanced monitoring for infants under 3 months
Long-Term Sequelae Monitoring
Neurological Complications
- Seizure disorders (10-15% of survivors)
- EEG if seizures occur post-discharge
- Anticonvulsant therapy as clinically indicated
- Cognitive impairment and learning difficulties
- Formal neuropsychological testing at 3-6 months
- Educational support referrals for children
- Motor deficits and cerebral palsy (particularly in neonates)
Sensory & Endocrine Sequelae
Hearing loss (most common sequela):
- Sensorineural hearing loss in 10-30% of survivors
- Conductive hearing loss from middle ear complications
- Hearing aid assessment and fitting if required
Visual impairment:
- Cortical blindness
- Visual field defects
- Optic neuritis
Endocrine sequelae:
- SIADH, diabetes insipidus
- Growth hormone deficiency in children
- Precocious or delayed puberty
Chemoprophylaxis
Meningococcal Disease Contacts
Close contacts requiring prophylaxis:
- Household members
- Childcare/school contacts with prolonged close contact
- Healthcare workers with unprotected mouth-to-mouth contact
- Laboratory workers handling specimens
Rifampicin
Rifadin
Adult Dose
600mg PO every 12 hours for 2 days
Paediatric Dose
Children 1-12 years: 10mg/kg PO q12h x 2 days
Infants <1 year: 5mg/kg PO q12h x 2 days
Infants <1 year: 5mg/kg PO q12h x 2 days
PBS Status
โ PBS General Benefit
Ciprofloxacin
Ciproxin
Adult Dose
500mg PO single dose
Paediatric Dose
Not recommended <18 years
PBS Status
โ PBS General Benefit
Ceftriaxone
Rocephin
Adult Dose
250mg IM single dose
Paediatric Dose
Children <15 years: 125mg IM single dose
PBS Status
โ PBS General Benefit
Timing: Ideally within 24 hours, effective up to 14 days post-exposure
Haemophilus influenzae Type b Contacts
Household contacts if:
- Unvaccinated children <4 years present
- Immunocompromised household members
- Childcare attendees <2 years
Pneumococcal Disease Contacts
Routine chemoprophylaxis not recommended. Consider for high-risk immunocompromised contacts in consultation with infectious diseases specialist.
Vaccination Strategies
Post-Meningitis Vaccination
Meningococcal ACWY
Nimenrix, Menveo
Indication
Survivors of invasive meningococcal disease
Timing
2-3 months post-illness recovery
PBS Status
โ PBS General Benefit for high-risk groups
Meningococcal B
Bexsero
Indication
Consider for close contacts and survivors
PBS Status
โ Not PBS Listed (private prescription)
Pneumococcal 23-valent
Pneumovax 23
Indication
All survivors of pneumococcal meningitis
Timing
2-3 months post-recovery
PBS Status
โ PBS General Benefit for eligible groups
Pneumococcal 13-valent
Prevenar 13
Indication
Consider in immunocompromised patients
PBS Status
โ PBS Restricted Benefit
Primary Prevention Strategies
Population-Based Measures
National Immunization Program vaccines:
- Meningococcal ACWY vaccine at 12 months
- Hib vaccine (pentavalent vaccine at 2, 4, 6 months; booster at 18 months)
- Pneumococcal conjugate vaccine (2, 4, 6 months; booster at 12 months)
- MMR vaccine (12 months and 18 months)
Special Populations
Aboriginal & Torres Strait Islander
Enhanced pneumococcal vaccination schedule
Additional meningococcal ACWY doses
Earlier commencement of some vaccines
Enhanced follow-up through Aboriginal Health Services
Cultural considerations in care delivery
Neonatal Follow-Up
Developmental pediatrician referral at 6 months
Early intervention services enrollment
Enhanced surveillance for cerebral palsy
Comprehensive hearing assessment program
Immunocompromised
Extended vaccination schedules
Additional vaccine types (e.g., Hib beyond age 5 years)
Specialist immunization clinic referral
Pregnancy & Breastfeeding
Group B Streptococcal screening in subsequent pregnancies
Genetic counseling if recurrent family history
Contraception counseling if teratogenic medications required
Public Health Notifications
Immediate notification (within 5 days):
- Invasive meningococcal disease
- Invasive pneumococcal disease
- Invasive Haemophilus influenzae type b disease
Quality Indicators and Audit
Clinical Outcome Measures
- Mortality rates by organism and age group
- Hearing loss rates at 6 months post-discharge
- Neurological sequelae rates
- Time to antimicrobial administration
- Appropriate chemoprophylaxis administration rates
System Performance Measures
- Public health notification timeliness
- Contact tracing completeness
- Vaccination coverage in contacts
- Follow-up appointment attendance rates
References
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Australian Government Department of Health. National Notifiable Diseases Surveillance System (NNDSS). Communicable Diseases Intelligence. 2023.
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National Health and Medical Research Council. The Australian Immunisation Handbook. 11th ed. Canberra: Australian Government Department of Health; 2023.
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Communicable Diseases Network Australia. Guidelines for the Prevention and Control of Meningococcal Disease. Australian Government Department of Health; 2022.
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Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship Clinical Care Standard. Sydney: ACSQHC; 2022.
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Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Meningitis and Encephalitis. 2023.
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Australasian Society for Infectious Diseases. Position Statement on Antimicrobial Stewardship in Healthcare Facilities. 2022.
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National Centre for Immunisation Research and Surveillance. Vaccine Preventable Diseases in Australia Annual Report 2022. Sydney: NCIRS; 2023.
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Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2022.
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Pharmaceutical Benefits Scheme. Schedule of Pharmaceutical Benefits. Australian Government Department of Health; 2023.
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van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016;22 Suppl 3:S37-S62.
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Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-84.
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Australian Group on Antimicrobial Resistance. Antimicrobial Resistance in Australia: 2022 Report. Sydney: AGAR; 2023.
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McGill F, Heyderman RS, Panagiotou S, Tunkel AR, Solomon T. Acute bacterial meningitis in adults. Lancet. 2016;388(10063):3036-47.
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RHDAustralia. Acute Rheumatic Fever and Rheumatic Heart Disease Guidelines. 2020.
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Australian Technical Advisory Group on Immunisation. Clinical advice for immunisation providers. Australian Government Department of Health; 2023.
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Curtis N, Finn A, Pollard AJ. Hot topics in infection and immunity in children IX. Arch Dis Child. 2017;102(11):1009-13.
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National Pathology Accreditation Advisory Council. Requirements for Medical Pathology Services. Australian Government Department of Health; 2022.
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Australian and New Zealand Intensive Care Society. ANZICS Clinical Trials Group Position Statement on Antimicrobial Stewardship. 2022.
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Infectious Diseases Society of America. Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017;64(6):e34-e65.
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Australian Government Department of Health. Guidelines for the prevention and control of meningococcal disease. Canberra: Commonwealth of Australia; 2015.
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Communicable Diseases Intelligence. Annual surveillance report on vaccine-preventable diseases in Australia, 2020. Commun Dis Intell. 2022;46.
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Australian Bureau of Statistics. Causes of Death, Australia. Canberra: ABS; 2022.